New Dimensions in Preoperative Assessment

G LudbrookUniversity of Adelaide & S.A.

Health

Disclosures and acknowledgements

Grant funds or commercial agreements:Medibank PrivateWA Health (SHRAC)Medtel Australia

Member, Clinical Governance Committee, RDNS

Customer of O’Brien Glass

Cost escalationSocietal expectations (time)Technology

Business challenges

Meeting the challenges of cost and qualityRemote, rapid access and communicationInformation processingTechnology

Conflicting pressuresIncreased demandLimited resources

Changing environmentChanging societyTechnology

Healthcare

Australian population projectionsour patient profile

Ageing population“middle-aged spread”

Old population“coffin shaped”

Young population“pyramid”

112 anaesthesia-related deathsInadequate preoperative assessment - 28% of casesInadequate preoperative management - 21% of cases

Anaesthetic OPD / Rooms Processes DSU / DOSASurgeon decides on operationPatient comes to clinicInput from multiple clinicians Nursing Anaesthetist Pharmacist Surgical internFurther testing +/- specialist referral off sitePossible repeat clinic visit

Exchange of dataHistoryExamination

Testing

Data integration and analysis

Management decisions

Surgeon decides on operationSome work up may occurSeen on DOS by anaesthetist

Processes of current preoperative workupElective surgery

Resource expensiveTime expensive – staff/patient

High qualityEfficient?

Resource inexpensiveTime inexpensive

Quality?Efficient?

Fit 17 yr old girlDental work

Mother and daughter lost a day off work

70 yr old repeat colonoscopyDefibrillating pacemaker inserted since last ‘scope

Processes of current preoperative workupWindscreen repair / replacement

Themes across industries

Process analysisNew technologiesEarly triage and streaming to best care pathways

Specific elements• Data exchange / communication• Data management & integration• Data analysis / Decision making• Management pathways

Remote communicationEarly triage and streamingComputer decision support

Virtual HospitalTelehealth Service

Medication Management via a videophone

Drivers for New Service• An aging population• Increased incidence of chronic diseases• Increased pressure on existing health services…• Need to increase client access ….• Maximise workforce efficiencies

New technologies + creative health services = innovative service delivery

Cost Effectivenesso Time reduction - 7 minutes vs 19 minutes o Cost reduction - 40% decrease

Risk and Safety

o Less intrusive for cliento Increased client control over medication

management

Client satisfaction

o Vast reduction in reported medication incidents – pharmacy delivery

Formal evaluation

Telemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic.Capampangan DJ, Wellik KE, Bobrow BJ, Aguilar MI, Ingall TJ, Kiernan TE, Wingerchuk DM, Demaerschalk BM.

To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations.

Neurologist. 2009 May;15(3):163-6

Neurologist. 2009 May;15(3):163-6.

Audio-visual(videoconference)

Telephone only

Correct acute stroke treatment decisions

98%(NNT 6)

82%

Specificity 98% 92%

Sensitivity 100% 58%

Thrombolysis eligibilityPPVNPV

94%100%

76%84%

Preoperative call centre pre-screening

Remote communication – phone or internetNon-clinician deliveredComputer assisted ‘smart’ questionaire

Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data

Preoperative medical pre-screening

517 patients from two tertiary referral centresCall centre pre-screening before elective surgeryQuality of data benchmarked against that collected in OPD55 anaesthetists involved in assessment

Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data

High quality data collected in 15 minutesWould in theory allow 50-60% of these patients to be seen on DOS

Data summary and processing

ConsistencyLegibility

Areas of concern highlighted

Pre-Admission Website: Patients are asked to complete an online assessment.

Healthbank PreOp Anaes Tab: If a disease needs further exploration the anaesthetist has a very powerful drilldown tool.

Decision making

Isaacs and Fitzgerald, BMJ 319 : 1618 1999Lam BMJ. 2000 July 22; 321(7255): 239

Evidence-based Consensus-based Opinion-based Eminence-based Vehemence-based Eloquence-based Providence-based Diffidence-based Arrogance-based

Expert consensus on preoperative testing

http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf

http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf

{

Collect data on patient factors which might predict OSABenchmark against sleep studiesMathematical models which predict likelihood of OSA

Determinants of OSAdata modelling

{

Reasonable performance using history aloneImprovement adding other factors (eg neck circumference)

Model performance

Positive Predictive Value

Grant, Ludbrook, O’Loughlin, Corcoran et al.

• Preoperative clinical decisions without hard evidence• Obtained opinions from 55 anaesthetists on 517 patients• Identified predictive factors• Built predictive models which identify what the “group”

would do for specific cases

Determinants of preoperative decisionsdata modelling

Grant, Ludbrook, O’Loughlin, Corcoran et al., submitted to BJA

Probability

Model ROC AUCCBP0.828

MBA0.861

Coags0.709

ECG0.903

ICU0.876

OPD0.852

Lumbar discectomy65 yr old maleBMI 35Treated hypertensionPrevious CVA

93% 93% 9% 99% 67% 90%

Decision support: pre-screening

“..... a medical practitioner will not be found negligent if they acted in a manner that was widely accepted in Australia, by a significant number of respected practitioners in the field…..”

Value of consensus in decision making

Maher and Burke, Medical Journal of Australia, 194(5), 253-255, 2011

Anaesthetic OPD / Rooms Processes DSU / DOSASurgeon decides on operationPatient comes to clinicInput from multiple clinicians Nursing Anaesthetist Pharmacist Surgical internFurther testing +/- specialist referral off sitePossible repeat clinic visit

Exchange of dataHistoryExamination

Testing

Data integration and analysis

Management decisions

Surgeon decides on operationSome work up may occurSeen on DOS by anaesthetist

Processes of current preoperative workupElective surgery

Anaesthetic OPD / Rooms Processes DSU / DOSASurgeon decides on operationPatient comes to clinicInput from multiple clinicians Nursing Anaesthetist Pharmacist Surgical internFurther testing +/- specialist referral off sitePossible repeat clinic visit

Exchange of dataHistoryExamination

Testing

Data integration and analysis

Management decisions

Surgeon decides on operationSome work up may occurSeen on DOS by anaesthetist

Processes of current preoperative workupElective surgery

Anaesthetic OPD / Rooms Processes DSU / DOSASurgeon decides on operationPatient comes to clinicInput from multiple clinicians Nursing Anaesthetist Pharmacist Surgical internFurther testing +/- specialist referral off sitePossible repeat clinic visit

Exchange of dataHistoryExamination

Testing

Data integration and analysis

Management decisions

Surgeon decides on operationSome work up may occurSeen on DOS by anaesthetist

Processes of current preoperative workupElective surgery

National E-Health StrategyDecember 2008

E-Health will: •Ensure the right consumer health information is electronically made available to the right person

at the right place and time to enable informed care and treatment decisions •Enable the Australian health sector to more effectively operate as an inter-connected system

overcoming the current fragmentation and duplication of service delivery •Provide consumers with electronic access to the information needed to better manage and

control their personal health outcomes •Enable multi-disciplinary teams to electronically communicate and exchange information and

provide better coordinated health care across the continuum of care •Provide consumers with confidence that their personal health information is managed in a secure,

confidential and tightly controlled manner •Enable electronic access to appropriate health care services for consumers within remote, rural

and disadvantaged communities •Facilitate continuous improvement of the health system through more effective reporting and

sharing of health outcome information •Improve the quality, safety and efficiency of clinical practices by giving care providers better

access to consumer health information, clinical evidence and clinical decision support tools •Support more informed policy, investment and research decisions through access to timely,

accurate and comprehensive reporting on Australian health system activities and outcomes.

AllscriptEmergisoftFirstnetHealthbanketc

OPD / Rooms Processes DSU / DOSASurgeon decides on operationPatient comes to clinic for workupInput from multiple clinicians Nursing Anaesthetist Pharmacist Surgical internFurther testing +/- specialist referral off sitePossible repeat clinic visit

Exchange of information

Inspection and auscultation

TestingDecision making

Management

Surgeon decides on operationSome work up may occurSeen on DOS by anaesthetist

New models of care

New models of careEarly triage

Call centre-based pre-screeningComputer smart questionnaire

MedicineNursing

Computer-generated guidelines

Call centre follow upRemote lab testingData collectionPhone follow up Informed consentStreaming to:

Outpatients vs DOSAAppropriate facility

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change……”